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Shepard, Cecelia NEW YORK STATE DEPARTMENT OF HEALTH 4rmitVital Records Section Burial - Transit iiiiiii Name First ��:: Middle Last Sex Ce e N,G. / ; S 1a 4 F. Date of Death 1 Age If Veteran of U.S. Armed Forces. o\' 2-9 1 2-01 1 8 S War or Dates N I A ) ; Place of Death i Hospital, nstitutio r 0 City,q`(owr' r Village nV ,\\C., Street Address 4-1&y ne5 1-1 otAs-e- o +4 o Pe. • , fe,• Manner of Death El Natural Cause D Accident Homicide Suicide n Undetermined 0 Pending 11. Jol Circumstances Investigation 8 Medical Certifier Name \ Title 0J©h,r\ SVou\e.,nbt�v igi Address 10Z Fa' S}rce=V , G\erS C-c,\\s, k`J /2201 Death Certificate Filed 1 District Number Register Number 1.0 City, Town or Village &-rp,n\ , \l e. £'IS6 3 Date , 1 Cemetery or Crematory ❑Burial O\ 1 c'Zlfl 2 c 1 l.p i c)`(12 Tr_v Cce.:er' oki-ur Address [gCremation QtAa C-,pa (1/ CAkanSbury , AT,) y?_ c LI Date Place Removed Z❑Removal and/or Held �= and/or Address 0 Hold 6.O Date Point of N Q Transportation. ; Shipment Ei by Common Destination - Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address ' • Permit Issued to Registration Number gi Name of Funeral Home 3t6:vt f-ir)L'Yr n3 c. / 1`ty 0/130 ,---- iiiiii. Address If �ra� 4,-) 'c:- C;. o /JS or Ayr /2. y . Name of Funeral Fjtm Making Disposition or to Whom iJ E Remains are Shipped, If Other than Above 4101 Address ll Permission is hereby granted to dispose of the human remains described above as indicated. < � Date Issued O I lam /‘ Registrar of Vital Statistics ii:v,A cus ignatur <» District Number S.7sq. Place G R A -i 'U-E I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: . WDate of Disposition I/1I//(, Place of Disposition RaiU4-0 er+An4'or.-.. t (address) uj (I CC (section) if/(lot numb r) (grave number) 2 Name of Sexton or Person-in Charge of Premises • L ,c,s' - .>i4 foi- Z (please print) • Signature L Title 6-01 tv t - (over) DOH-1555 (9/98)